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Doctor of Medicine
Effect of inferior pulmonary ligament division on residual lung volume and function
after right upper lobectomy
The Graduate School of the University of Ulsan
Department of Medicine
Donghee Kim
[UCI]I804:48009-200000007629 [UCI]I804:48009-200000007629 [UCI]I804:48009-200000007629 [UCI]I804:48009-200000007629
Effect of inferior pulmonary ligament division on residual lung volume and function
after right upper lobectomy
Supervisor : Hyeong Ryul Kim
Submitted to
the Graduate School of the University of Ulsan In partial Fulfillment of the Requirement
for the Degree of
Doctor of Medicine
by
Donghee Kim
Department of Medicine
Ulsan, Korea
February 2018
Effect of inferior pulmonary ligament division on residual lung volume and function
after right upper lobectomy
This certifies that the dissertation of Donghee Kim is approved.
Chang-Min Choi Committee Chair Dr.
Eun Jin Chae Committee Member Dr.
Hyeong Ryul Kim Committee Member Dr.
Department of Medicine
Ulsan, Korea
February 2018
Abstract
Objective: Though the detailed procedures of lobectomy have been well structured,
performance of inferior pulmonary ligament (IPL) division has not been determined
definitely during upper lobectomy. Division of IPL could contribute on postoperative
pulmonary conditions; we evaluated the influence of IPL division on alteration of
anatomy, residual lung volume, and overall pulmonary function after lobectomy.
Methods: We evaluated 53 patients (mean age at operation 61±9 years) who
underwent video assisted thoracoscopic surgery (VATS) lobectomy of right upper lobe
(RUL) for early stage lung cancer in Asan medical center in Korea from January
2011 to April 2014. The patients who had pleural adhesion or experienced
thoracotomy approach were excluded. They were categorized in two groups based on
division of IPL; preservation group (group P, n=22), division group (group D, n=31).
Bronchial angle measurement between bronchus intermedius and right middle lobe
(RML) bronchus taken on pre-and postoperative chest computed tomography (CT)
image, which was performed at 3 to 6 months after the operation. Right lower lobe
(RLL) and RML volume was measured with the same CT images
three-dimensionally. Existence of atelectasis, dead space and fluid collection was
based on same CT. Postoperative pulmonary function within 1 year was compared
with preoperative pulmonary function tests (PFT).
Results: Mean age was not statistically different between two groups (58.9±9.5 years
in group P vs 62.4±8.5 years in group D, p=0.168). The prevalence of atelectasis
(8/22, 36.4% in group P vs 11/31, 35.5% in group D, p=0.417), dead space which
was filled with air (2/22, 9.1% in group P vs 7/31, 22.6% in group D, p=0.197),
pleural effusion (9/22, 40.9% in group P vs 11/31, 35.5% in group D, p=0.688) was
not statistically different between two groups. There were no significant differences in
postoperative remaining lung volume (1757±400 ml in group P vs 1844±477 ml in
group D, p=0.487). Also, there was no difference in postoperative bronchial angle
between two groups (109.7˚±13.7˚ vs 109.9˚±13.5, p=0.954). There were no
significant differences in postoperative FVC and FEV1 (3.25±0.63 in group P vs
3.05±0.63 in group D, p=0.289; 2.27±0.34 in group P vs 2.26±0.46 in group D,
p=0.891). However, group D experienced more considerable loss of FVC after the
operation than group P (-0.16±0.25 liters in group P vs -0.42±0.33 liters in group D,
p<0.01). The amount of postoperative decrease of FEV1 is not significantly different
(-0.31±0.2 liters in group P vs. -0.26±0.22 liters in group D, p=0.475).
Conclusions: Division of IPL did not show any benefit in postoperative lung volume,
function, prevalence of complications during lobectomy of RUL. Moreover,
preservation of IPL can contribute to conserve the pulmonary functional capacity
better. Therefore, division of IPL should be performed in properly selected patients.
Key words: Lung volume, Lung function, Bronchial angle, Lobectomy of right upper
lobe, inferior pulmonary ligament, Lung cancer
Contents
Abstract i
Contents iv
List of figures, tables ＆ abbreviations vi
Introduction 1
Methods 2
1. Patient population 2
2. Operative method and postoperative management 3
3. Volume measuring 4
4. Bronchial angle measuring 5
5. Statistical analysis 8
Results 9
1. Patients and outcomes 9
2. Volume 12
3. Bronchial angle 16
4. Pulmonary function tests 16
Discussion 19
Conclusions 27
References 28
Korean abstracts (국문 요약) 34
List of figures, tables ＆ abbreviations
Figure 1. The methods for bronchial angle measuring. 7
Figure 2. Overall survival curve of patients stratified by division of inferior
pulmonary ligament 10
Figure 3. Measured perioperative lung volumes in each lobes 15
Figure 4. Measured pulmonary function test values 18
Table 1. Baseline characteristics 11
Table 2. Measured perioperative lung volumes in each lobes 14
Introduction
After wide acceptance of anatomical resection for lung cancer treatment, lobectomy
has been the treatment of choice for the lung cancer and it has been systematically
done with safety 1,2. However, division of inferior pulmonary ligament (IPL) still has
been in discuss with few studies because it could reduce the dead space while
causing the possibility of developing atelectasis after the operation 2. Meanwhile,
during the surveillance of the patients who underwent lobectomy, delayed atelectasis
could be found often even several months over after surgery, in especially right
middle lobe (RML) atelectasis after lobectomy of right upper lobe (RUL). Atelectasis
can affect remaining lung volume anatomically and functionally. Therefore, we
compared several parameters in computed tomography (CT) scanning, pulmonary
function tests (PFT) and other clinical outcomes between two groups whether the
performance of IPL division.
Methods
1. Patient population
We retrospectively reviewed the data from 181 patients who underwent video-assisted
thoracoscopic surgery (VATS) lobectomy of RUL for lung cancer in our institution
from January 2011 to April 2014. The patients who had interstitial lung disease or
emphysematous destruction before the operation were excluded. And the patients who
had partial or diffuse pleural adhesion or the patients whose surgical procedure was
changed to thoracotomy approach from VATS were also excluded. The remaining 53
patients were divided into 2 groups based on procedures to the IPL: preservation
(Group P, n=22) and division (Group D, n=31).
All patients underwent routine preoperative and cancer staging examination including
chest CT and PFT. These examinations were performed before the operation within 1
month. Postoperative surveillance data including clinical records, chest roentgenogram
(X-ray), chest CT and PFT were collected. The presence of atelectasis, dead space or
any results which were collected from CT images were based on the CT scanning
which was done at 3 to 6 months after surgery during follow up periods.
Postoperative results of PFT were collected from those performed about 1 year after
the operation.
2. Operative method and postoperative management
All operations were done by two surgeons. The procedure was performed under
general anesthesia followed by intubation with a double lumen endotracheal tube,
allowing single-lung ventilation. The location of the tracheal tube was always checked
with bronchoscopy. The patient was positioned in the left lateral decubitus position.
The VATS lobectomy was performed using three incisions. Endoscopic staplers were
used for individual ligation of the hilar structure, including the pulmonary vessels and
bronchus. No patients underwent fixation of RML to prevent lobar torsion at the end
of all procedures. Same oncological principles, such as complete anatomic resection
with adequate margins and mediastinal lymph node dissection were implemented.
Routinely, all patients extubated after the operation, and admitted to ward or
intensive care unit according to the patient’s baseline conditions. Chest X-ray was
performed on daily basis and chest tube was removed if there is no air-leakage and
an amount of drain had been decreased to 200~250 ml per day with the
consideration of patient’s body weight. At the day after removal of draining tube,
most of the patients were discharged.
3. Volume measuring
Using in-house software, right lobe segmentation was semi-automatically performed.
Lung, airway and pulmonary vessel were extracted using thresholding the simplest
method of image segmentation, 3D region growing with semi-automatic interaction.
Lobe segmentation was performed with 3D free-formed surface fitting on possible
fissure voxels which were detected by hessian matrix analysis within lung except
dilated airway and pulmonary vessel regions. And then, manual editing of the
detected fissure and lobe split were performed. Using the result of lobe segmentation,
each lobe volume was automatically calculated. All volume measurement procedures
were done by one radiologic specialist.
4. Bronchial angle measuring
Bronchial branching angle of right middle lobe was obtained by finding each
midpoint of the bronchus. First of all, a triangle was made with these three points
(midpoint of bronchus intermedius, RML bronchus before the branching of segmental
bronchus, center of RML bronchus branching site), and two-dimensional coordinates
was obtained in transverse section of CT imaging which has the thinnest slice depth.
The coordinates of z-axis could be obtained from the thickness of sliced computed
tomography image. Length of each side of the triangle was calculated by the
Pythagorean theorem with three dimensional coordinates in each point. The right
middle lobar branching angle was calculated by the second law of cosines with the
calculated length of each side. This method is illustrated in figure 1.
Figure 1. The methods for bronchial angle measuring. Three-dimensional coordinates
of each point (center of right bronchus intermedius, right middle lobe bronchus and
branching site) were collected. Branching angle was calculated by second law of
cosines after calculating the distances from these three points by Pythagorean
theorem.
* Note that the height of triangle is expressed longer than actual size to promote the
understanding of method.
5. Statistical analysis
Statistical analysis was performed using IBM SPSS 22 Software (IBM Co., Chicago,
IL, USA). Continuous values are expressed as mean ± standard deviation. χ2 test or
Fisher exact test were used for categorical variables between the groups. Unpaired
Student’s t-test and the Mann-Whitney test were used for discrete and continuous
variables. A paired T-test was used to test between pre- and postoperative variables
in the same patients. A value of p less than 0.05 was considered significant.
Results
1. Patients and outcomes
The mean age of the patients is 58.9 years in group P and 62.4 years in group D
(p=0.168). Age, cancer stage, hospital stay was not different among the two groups.
1 patient in group D underwent neoadjuvant chemotherapy. No patients required
re-admission or further treatment for surgical complications. There were no
differences between two groups in incidence of atelectasis, dead space and prolonged
pleural effusion. Overall survival rate was not different among two groups (Figure 2).
Detailed characteristics are summarized in Table 1.
Figure 2. Overall survival curve of patients stratified by division of inferior
pulmonary ligament
Preservation group (n=22)
Division group (n=31)
p value
Age (years) 58.9±9.5 62.4±8.5 0.168
Sex 0.799
Male 12 (54.5%) 18 (58.1%)
Femele 10 (45.5%) 13 (41.9%)
Hospital stay (days) 5 (IQR; 5-7) 5 (IQR; 5-7) 0.251
Histology 0.112
Adenocarcinoma 20 22
Squamous cell carcinoma 1 5
Others 1 4
Pathological cancer stage 0.304
I 16 27
II 1 2
III 4 1
IV 1 1
Follow up duration (y) 4.45
(IQR; 3.52-5.07)
4.00
(IQR; 3.68-4.79) 0.417
Atelectasis 8 (36.4%) 11 (35.5%) 0.948
Dead space 2 (9.1%) 7 (22.6%) 0.197
Delayed pleural effusion 9 (40.9%) 11 (35.5%) 0.688
5 year survival rate (%) 86.4 75.4 0.431
IQR, interquartile range
Table 1. Baseline characteristics (n=53)
2. Volume
The preoperative volume of RML, RLL, and sum of these in group P were revealed
as 385±149 ml, 1018±296 ml and 1403±358 ml, respectively. These values of group
D were 396±144 ml, 1143±292 ml and 1538±358 ml, respectively. The difference
was not significant between two groups in these values (p=0.787, 0.133 and 0.180),
respectively. The preoperative whole lung volumes were not significantly different
between those groups (2237±511 ml in group P and 2444±445 ml in group D,
p=0.124), respectively.
Postoperatively, volume of RML in group P was 363±168 ml and that in group D
was 367±188 ml (p=0.947). Postoperative volume of RLL in group P was 1393±364
ml and in group D was 1477±402 ml (p=0.440). Sum of RML, RLL volume was
1757±400 ml in group P and was 1844±478 ml in group D (p=0.487). There were
no differences in these values between two groups. The whole lung volume after
right upper lobectomy (sum of RML, RLL volumes) represented 81% of preoperative
whole lung volume in group P and 75% in group D. Lower proportion was found in
group D, however, this finding was not statistically significant (p=0.225).
Postoperatively, RLL volume was increased significantly in each groups (p<0.001 in
both groups). However, RML volume was slightly decreased in both group, however,
there were no statistical significance (p=0.32 in group P, p=0.154 in group D). The
amount of volume loss before and after the operation was calculated, however, there
were no differences between two groups. Differences of RML volume was revealed
as -21±99 ml in group P and -29±111 ml in group D (p=0.796), and differences of
expanded RLL volume was found as 375±303 ml in group P and 335±294 ml in
group D (p=0.626). Differences of sum of RML and RLL volume was 354±354 ml
in group P and 306±350 ml in group D (p=0.624). These findings are summarized in
table 2 and figure 3.
Preservation group (n=22)
Division
group (n=31) p value Preoperative (ml)
RUL 835±241 906±186 0.233
RML 385±149 396±144 0.787
RLL 1018±296 1143±292 0.133
RML+RLL 1403±358 1538±358 0.18
Whole lung 2237±511 2444±445 0.124
Postoperative (ml)
RML 363±168 367±188 0.947
RLL 1393±364 1477±402 0.44
RML+RLL 1757±400 1844±478 0.487
Difference (ml)
RML -21±99 -29±111 0.796
RLL 375±303 335±294 0.626
RML+RLL 354±354 306±350 0.624
Postoperative whole lung
/ preoperative whole lung 0.81±0.19 0.75±0.13 0.225
RUL, right upper lobe; RML, right middle lobe; RLL, right lower lobe Table 2. Measured perioperative lung volumes in each lobes
RUL, right upper lobe; RML, right middle lobe; RLL, right lower lobe; dRML, difference between pre- and postoperative right middle lobe; dRLL, difference between pre- and postoperative right lower lobe; dRML+RLL, difference between sum of pre- and postoperative right middle lobe and right lower lobe
Figure 3. Measured perioperative lung volumes in each lobes
3. Bronchial angle
The measured preoperative angle between RML bronchus and bronchus intermedius is
found as 135.8˚±7.5˚ in group P and 136.6˚±6.6˚ in group D (p=0.668). These angles
significantly decreased after the operation (-26.0˚±13.4˚ in group P (p<0.001)and
-26.7˚±13.6˚ in group D (p<0.001)). The amount of angle change was not different
between two groups (p = 0.869). Also, there was no difference in postoperative
bronchial angle between two groups (109.7˚±13.7˚vs 109.9˚±13.5, p=0.954).
4. Pulmonary function tests
Postoperative PFT surveillance was performed except 5 patients. The reasons for
missing of PFT were follow-up loss, mortality or morbidity. The preoperative mean
values of forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1)
in group P were 3.40±0.69 liters and 2.54±0.52 liters, respectively. These values in
group D were 3.44±0.62 liters and 2.47±0.52 liters, respectively. There was no
significant difference between two groups (p=0.856, 0.678). The postoperative FVC,
FEV1 in group P were 3.25±0.63 liters and 2.27±0.34 liters, respectively. And these
values in group D were 3.05±0.63 liters and 2.26±0.46 liters, respectively. There
were no significant differences between groups in these values (p=0.289, 0.891).
However, the amount of postoperative loss of FVC is significantly different between
two groups (-0.15±0.26 liters in group P vs. -0.42±0.33 liters in group D, p=0.005).
The amount of postoperative decrease of FEV1 is not significantly different
(-0.32±0.21 liters in group P vs. -0.26±0.22 liters in group D, p=0.334). These
findings are illustrated in figure 4.
FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; dFVC, difference between pre- and postoperative forced vital capacity values; dFEV1, difference between pre- and postoperative forced expiratory volume in 1 second values
Figure 4. Measured pulmonary function test values
Discussion
The preservation of IPL can affect on alteration of the volume, anatomy and
function, and we want to analyze these outcomes. However, because of possible
theoretical interferences from thoracotomy approach on postoperative changes, we
selected the patients who underwent VATS lobectomy only. VATS approach has
several advantages over thoracotomy approach such as preservation of pulmonary
function, reduced pain and better prognosis 3-5. Moreover, greater incision and rib
fracture or resection usually required during thoracotomy approach. Therefore, chest
wall deformity can be more profound, and the movement of chest wall can be more
interrupted also when thoracotomy approach is compared to VATS approach. Hence,
chest wall compliance and pulmonary function could be more deteriorated during
thoracotomy approach 6. Moreover, pleural adhesion with chest wall can be more
intense because thoracotomy requires greater size of incision and has more direct
manipulation to pleural surface and visceral organs with the surgeon’s hand and
instruments during the procedures. Therefore, pleural irritation and direct contact with
greater wound can make the adhesion extensive. In addition, postoperative
inflammatory change within lung parenchyme can result in greater incidence of
atelectasis or associated loss of pulmonary function and anatomical alteration.
Meanwhile, IPL makes a lower lobe to adhere with the mediastinal structures from
diaphragmatic folding inferiorly, to hilar level superiorly, especially inferior pulmonary
veins. During the performance of lower lobectomy, division of IPL must be done,
however, it is not a routine procedure during upper lobectomy 7,8. The choice of
performing IPL division is mainly based on surgeon’s preference. There has been a
concern about whether this procedure will provide favorable outcomes with fewer
complications.
During the division of IPL, some benefits could be resulted by releasing residual
lower lobes. After removal of lung, the cavity, which had been occupied with lung
to be removed, is created and has to be filled with remnant structures. Reposition of
mediastinal structures toward the side of operation and elevation of diaphragm may
count on filling cavity 9. However, major sources of filling cavity are overexpansion
and redistribution of remnant lung in the cavity. Therefore, it has been thought that
release of lower lobe from mediastinal adherence can facilitate filling the dead space,
theoretically 2.
However, too much relocation of remnant lung may compromise lung function by
kinking and obstruction of rearranged bronchus 10,11. Especially, after RUL lobectomy,
superior and posterior reposition of RML can be observed frequently. In some
patients, postoperative directional change of middle lobe bronchus might be slightly
heavy, therefore, bronchial kinking and atelectasis could be observed. Moreover, these
changes could impair the residual pulmonary function 12,13.
Meanwhile, division of IPL and upward movement of residual lobes has benefits,
either.
This procedure can reduce dead space after the operation. Enough expansion and
reposition can reduce the dead space, however, remaining IPL can interfere the
expansion. Dead space is also associated with prolonged need for draining effusion,
moreover, there are some risks of infection. Therefore, dead space can make patients
to require more times to recover or needs for further intervention.
There have been theoretical debates as mentioned above, however, we could not
demonstrate the differences of outcomes about complications such as delayed effusion
that requires prolonged hospitalization or frequency of obvious atelectasis between
two groups. And any incidence of complications and long term survival was not
different also.
Previous report performed by Seok et al in 2015 declared that dissecting IPL during
right upper lobectomy can significantly change bronchial angle transversely with
minimal benefits 14. As mentioned above, we compared the angle between RML
bronchus and bronchus intermedius three-dimensionally. Because the angle does not
located within coronal or horizontal plane strictly, the measurement of angle can’t be
taken easily. Moreover, because RML tends to move posterior and superior direction
in the same time after RUL lobectomy, just comparing the angle change in
two-dimensional plane cannot explain actual complex rearrangement. So, we compared
the narrowest angle between these bronchus, and the angle was decreased after
lobectomy significantly in all groups. However, there were no differences between
two groups divided by performance of IPL division. It is thought that the division of
IPL could count on the degrees of angle change and the amount of relocation of
RML, however, there might be something that influences more than division of IPL
on RML movement. For example, completeness of major fissure, the amount of hilar
dissection and mobilization can influence the RML movement also.
However, if the higher resolution and delicate slice of CT had been obtained, more
precise angle can be measured. Therefore, more meticulous studies are warranted to
explain the different results with previous studies and to get a more information
about bronchial angle change.
Bu et al reported about PFT analysis and volume measuring by CT scan previously.
There are no differences between two groups divided by division of IPL most of
findings. However, the pulmonary capacity and FEV1 were significantly different
between two groups after right or left upper lobectomy in that study 15. Our study
was confined in the patients who underwent RUL lobectomy because we thought that
volume compromise and atelectasis were mainly found in RML after RUL lobectomy.
As seen in result, there were no significant differences between two groups in their
volume change of RML, RLL or total lung volume. Meanwhile, RLL volume was
significantly increased after the operation in both groups as we thought that it would
be overexpanded, however, RML volume did not changed significantly. These finding
can be thought as overexpansion of RLL can compress RML not to be
overexpanded. Moreover, relative RML bronchial narrowing after rearrangement of
RML can impair RML capacity.
We also compared PFT findings, however, we could not find differences except
amount of FVC loss. More profound loss of FVC was found in the patients who
underwent IPL division and relative lower result of FVC was found also. We
thought that loss of FVC can be matched with postoperative proportional volume loss
in CT findings. Even though there were no significant differences between two
groups, group D has relative greater proportional loss of lung volume. Paradoxically,
division of IPL can compromise the expansion capacity of remaining lung after the
operation. Meanwhile, this finding could be resulted by atelectasis or dead space.
However, because there was no significant difference in number of patients suffering
definite atelectasis or dead space on CT scan, it is hard to conclude that the FVC
loss is caused by atelectasis or dead space. Nevertheless, we only concluded that the
prevalence of dead space, pleural effusion and atelectasis is not different between two
groups rather than comparing the amount or severity of complications in this study.
Therefore, further studies which investigate about these volumetric information could
be helpful. Moreover, analysis about pulmonary capacity in greater patient population
could be worthwhile to provide the effect of IPL division on patient’s status.
There are other concerns about possibility of proper dissection of mediastinal lymph
nodes without IPL division. Though proper dissection of inferior mediastinal node
can be achieved without IPL division, some nodes that lies on IPL or paraesophageal
nodes can be done only after IPL division. However, lung cancer in RUL rarely
metastasize to inferior mediastinal nodes as discussed in earlier studies 16,17.
Moreover, survival detriment was not found in the patients who underwent selective
mediastinal lymph node dissection 18. We also cannot found inferior lymph node
metastasis or survival difference in IPL-dissected patients, therefore, we thought that
the complete dissection of lower mediastinal lymph node during RUL lobectomy does
not effect on cancer related survival.
Conclusions
We conclude that division of IPL does not cause any significant benefits in lung
volume or bronchial angle of right middle lobe which is measured in CT. However,
division of IPL can compromise functional capacity more. Dissection of IPL is
recommended in selected patients. If other useful parameters in PFT (i.e. diffusion
capacity of carbon monoxide, residual volume) could be applied in analysis, the
obliteration of pulmonary function or the effects of right middle lobe atelectasis after
IPL division could be elucidated better. Moreover, review of the symptoms such as
long-lasting cough several months after the operation could be valuable information
with correlation of the results. However, because this study is conducted as
retrospective manner, the clinical symptoms could not be fully obtained accurately.
This study also has other limitations because of designed retrospectively, small size
of samples within single center, therefore, further investigation is required to analyze
detailed information.
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Korean abstracts (국문 요약)
서론: 비록 폐엽 절제술의 상세한 방법이 잘 정립되었으나, 상엽절제술에 있어서
페간막 절제 여부는 아직 명확하게 정해지지 않았다. 폐간막 절제는 수술 후 폐
상태에 영향을 미칠 수 있기 때문에, 본 논문에서는 폐간막 절제가 해부학적, 잔
존 폐 용량 및 기능에 미치는 영향을 분석하고자 하였다.
연구 재료와 연구 방법: 서울아산병원에서 2011년 1월부터 2014년 4월까지, 조
기 폐암으로 흉강경하 우상엽 절제술을 시행한 53명 (수술 시 평균 나이 61±9
세)를 대상으로 하였다. 환자들 중 흉막 유착이 심하였거나 수술 시 개흉술로 전
환이 된 경우는 제외하였다. 환자들은 폐간막의 절제 여부에 따라 두 군으로 나
누어졌다; 보존 군 (22명), 절제 군 (31명). 수술 전 및 수술 3에서 6개월 후에
시행한 폐 전산화 단층 촬영 영상(CT)에서 중간 기관지와 우중엽 기관지 사이의
기관지 각도를 측정하였다. 우하엽 및 우중엽의 3차원적인 용량 또한 같은 영상
에서 측정되었다. 무기폐, 사강 및 흉수 저류의 유무도 같은 영상에서 조사하였
다. 수술 후 약 1년경에 시행한 폐기능 검사도 수술 전과 비교하였다.
결과: 양 군에서 평균 나이는 의미있는 차이를 보이지 않았다. (보존 군,
58.9±9.5세; 절제 군, 62.4±8.5세; p=0.168). 무기폐 (보존 군, 8/22, 36.4%;
절제 군, 11/31, 35.5%; p=0.417), 사강 (보존 군, 2/22, 9.1%; 절제 군, 7/31,
22.6%; p=0.197), 흉수 저류 (보존 군, 9/22, 40.9%; 절제 군, 11/31, 35.5%;
p=0.688) 의 빈도는 양 군에서 차이가 없었다. 수술 후 폐 용량도 양 군에서 차
이가 없었다 (보존 군, 1757±400 ml; 절제 군, 1844±477 ml; p=0.487). 또한,
기관지의 각도 또한 양 군에서 차이가 없었다 (보존 군, 109.7˚±13.7˚; 절제 군,
109.9˚±13.5; p = 0.954). 수술 후 강제폐활량(FVC), (보존 군, 3.25±0.63
liters; 절제 군, 3.05±0.63 liters ; p=0.289) 및 1초간 강제호기량(FEV1), (보
존 군, 2.27±0.34 liters; 절제 군, 2.26±0.46 liters; p=0.891) 에서도 양 군에
서 차이를 보이지 않았다. 그러나, 절제 군에서 강제폐활량의 감소가 더욱 뚜렷
하였다 (보존 군, -0.16±0.25 liters; 절제 군, -0.42±0.33 liters; p<0.01). 1초
간 강제호기량의 감소량은 양 군에서 의미있는 차이가 나타나지 않았다 (보존
군, -0.31±0.2 liters; 절제 군, -0.26±0.22 liters; p=0.475).
고찰 및 결론: 폐간막의 절제는 우상엽 절제술에서 폐 용적 및 기능, 합병증의
빈도에서 의미있는 차이를 보이지 못하였다. 또한 폐간막의 보존은 수술 후 강제
폐활량의 감소량을 줄이는 데 기여할 수 있었다. 따라서 우상엽 절제술에 있어서
폐간막의 절제는 적절히 선택된 환자에서만 시행하여야 할 것으로 보인다.
